You don’t have to be the Smartest, but you do have to be the Most Prepared

July 4th, 1998. I will always remember the sound of the blades beating the wind as Vanderbilt LifeFlight arrived at the Pegram, Tennessee 4th of July celebration. I was 15 and had no idea what a public relations (PR) event was at the time. What I did know is that it was the coolest thing I had ever heard and witnessed up to this point in my life. I don’t remember the crew’s names, type of helicopter, or how many patient flights they had completed that day. But what I do remember is that “this” is what I wanted to do when I grew up.

Fast forward 13 years. July 4th, 2011. I was preparing to start my first flight nurse position. Med-Trans Corporation D/B/A Meducare was opening a base in Charleston, SC and I was part of the inaugural crew. The menagerie of thoughts and emotions running through my head ranged from excitement, nervousness, happiness and glee to frequent episodes of sweating and nausea. You name it, I was feeling it at the time. But as the days got closer to the base opening, all I could think about was, “Am I ready”? The more I thought about what was ahead of me, the more I knew I had to learn.

Early in my career with the TN-1 Disaster Medical Assistance Team (DMAT), I was coached that a team member should be humble and teachable. I did not want to fall into the category of “she doesn’t know what she doesn’t know.” So my mind went back to, “Am I ready?” I had thought long and hard about this. I knew I could adequately take care of a patient in the back of an ambulance and in the Emergency Department, but could I do it in this new environment 1,000 feet in the air?

The answer was yes! I was going to figure this out. This is what I had wanted to do for the last 13 years. I was going to do everything in my power to mitigate the stress and anxiety that came with:

Accepting a flight

Landing on my first scene

Interacting with ground crews and hospital staff that were under stress

Being the flight crew taking the patient from the ambulance for the first time

Loading/unloading under a running rotor system

Listening to the pilot and air traffic control while looking out for obstacles

Trying to give a thorough but quick and concise report to the hospital

Providing the absolute best patient care my partner and I could provide

Remaining safe and coming home at the end of my shift

One of the first items I knew I needed to work on was airway management. Up until this point, I had never intubated anyone, using Rapid Sequence Induction (RSI). The EMS agency I worked for didn’t allow it and I had only assisted with the procedure in the ER. I had never been asked to come up with medication doses myself or to perform the actual intubation with just a partner and me. I had never used a Video Laryngoscope. I had also never really thought about what medications were/are best in certain scenarios. Honestly, I didn’t know. I truly had no idea. So what did I do? I began to study and ask my new partners around me for help. My thoughts began to go from “Am I Ready” to “Am I prepared”? I would quickly learn that I didn’t have to be the smartest provider in the room, but I did have to be the most prepared.

Am I Prepared?

Was I prepared? Was I truly prepared for anything that could come my way? This started with asking my partners to “Talk to me about RSI’ing someone”. If we are faced with x scenario, what would we do? What if the patient is y, what should we do?” Those questions went on for hours. From there I immersed myself in the books and began to study. I learned the normal dosing for Etomidate is 0.3mg/kg. How was I going to remember this? I knew! I would calculate this dosage for every patient transport that we went on, even if the patient wasn’t going to need to be RSI’d. This would give me good practice and hopefully I would commit the dosage to memory. I then learned about Succinylcholine. I learned it was a depolarizing agent with typical dosing from 1.0 to 1.5mg/kg in adults. Again, I would calculate this on every patient transport, for the practice, and in hopes, I would commit this to memory. At this point, I admittedly still hadn’t learned all the actions, adverse effects, and dosage ranges for all medications we carried, but that would come. The only other medication we carried for RSI besides our narcotics was Vecuronium. I admittedly only knew that most patients received between 5mg and 10mg but my goal was to give patients enough pain and sedation medications that we didn’t have to use it, so I could learn more about that later.

For the next few weeks, I studied and studied and studied. I ran through different patient scenarios; working on medication dosages, thinking about what I should carry on me at all times, and where I would write down information [on my glove, in a book, on a folder, or maybe an EKG strip]. What pens would I carry? How many did I need? How many syringes did I need? Should I carry flushes or was our supply in the bag enough? I wanted to think about everything I could potentially face before it ever happened.

My first flight as a second crew member was not an RSI, but it did come around the fifth flight. At this point I realized I always needed to have a 3ml, 10ml and 20ml syringe (those of you smirking right now…you’re welcome) with needles, a flush or two, alcohol preps, two blue pens, a black sharpie, scissors, ear protection, the amazing reference cards [one of our nurses had developed with medication dosages] and a few of our other items. I had decided I would use the back of the patient paperwork for calculations I was doing on the way to a flight. I’d write down all the quality indicators I needed to hit (e.g. 12-lead EKG and blood glucose for stroke patients). This alone would rescue me if I became stuck in a patient scenario. At this point, I also added writing down the amount of volume I would give for each medication dosage and other calculations such as 20ml/kg fluid boluses, tube sizes, etc…

The RSI took place in the back of an ambulance and it was not what my partner and I were expecting to walk into when we arrived on scene. While inflight my partner and I discussed what we would do when we landed. This included what we needed to bring, who would grab what, what door of the ambulance each of us would walk in and if we were going to ask the pilot to stay hot or not. This was planning. This was establishing a routine so that when everything outside of our control began to happen, we could fall back on our preparation to see us through. The outside of our control items began to happen immediately. Not only did the patient need to be RSI’d, he needed IV access. EMS had attempted access twice without success. The patient was unstable. In a split second, I decided to grab the EZ-IO gun and place a line in the patient’s right leg. While this was happening, my partner began to prepare for the intubation. She was an absolute expert in using the GlideScope and airway management. I knew she would be ready quickly, so I needed to hurry up and be ready with the medications. If it had not been for the weeks of practice and planning prior to this moment I would have probably fallen apart. But I didn’t. I didn’t freeze or panic at all. On the way to this flight we had worked up multiple RSI dosages AND the volume we would need. In 60 seconds I had three syringes of medications ready to go. This included that handy 20ml syringe full of Etomidate. The patient was successfully RSI’d and pre/post medicated with pain medications. Our skid to skid time was approximately 12 minutes and the patient was successfully transported to the local trauma center.

How do I Stay Prepared?

So why do I write this? It is not to reminisce; although I absolutely loved flying for Meducare and with my partner, Kelly. It is to prove the point that just because you are new or not as educated as everyone around you, you can still provide phenomenal care. In my opinion, you must!!! Being unprepared should not be allowed. If you have not worked in EMS or on an aircraft, you have to set yourself up for success by controlling all the items that are within your ability, so that when the crazy starts you can say, “I got this”. If you are new, and not practicing medication dosages on the way to every flight, then start. You don’t have to know your patient weight. You work up a range from 50kg to 150kg and then go from there. If you identify ACLS or PALS as a weakness of yours, then on every flight begin working those dosages up. Not just for medications, but also for electricity you might need to administer for defibrillation and cardioversion. If you know you are going to a STEMI patient, write down all the medications you may give and their normal doses. If you have time, pre-set your pump up (yes, even our triple channels will hold those numbers). Write down the care items you know you need to provide. In the moment, begin to check them off: 12-lead, heparin bolus given, nitro paste applied, asked about pain and addressed, etc…

Preparation is the key to our success in an environment filled with stress. Set yourself up for success, and never stop seeking knowledge from those around you. This form of preparation is called “Mental Practice” or “Mental Rehearsal” in the sports environment. Mental practice refers to the cognitive rehearsal of a task in the absence of overt physical movement. (Driskell, Cooper & Moran, 1994) How many times do you think Tom Brady visualized throwing the perfect touchdown pass? In a recent documentary, “Tom vs Time”, Tom says, “If you want to perform at the highest level, you have to prepare at the highest level mentally”. He goes on to say, “The more we practice that habit, skill or behavior, the more automatically our brains recognize it”. Mental practice is slowly making its way into the medical environment. In 2015 an Australian team conducted research on how Medical Emergency Teams (MET’s) could perform better under stress and improve patient outcomes. (Fein, Mackie, Chernyok, O’Quinn & Ahmed, 2015) They came up with 6 habits.

I am a true believer in the adoption and practice of the six stated habits. Here is how I have personally adopted them into my work routine:

Arriving to work 15 minutes early with my uniform neat, clean and on. This includes boots that are clean and polished. Take pride in your flight suit…It’s not just a flight suit…one day I will explain that one.

Having on me two blue pens, a sharpie, scissors, a 3ml, 10ml and 20ml syringe with needle, a couple of flushes, my reference cards, extra paperwork in my pocket, my medication guide, the narcotics once shift change happens, my helmet out of the bag, and Night Vision Goggles on if at night.

Having an aircraft that my partner and I have checked off for the day or night. Yes, even if you are only on for a 12-night shift, you should still be checking off your aircraft.

Attending shift brief with the pilot, dispatch and my partner. Educate yourself early on what you may expect today in regards to maintenance, weather and/or PR events.

Be nice and kind.

Be humble and teachable, but also confident in your learned and practiced abilities.

Understand, “you don’t know what you don’t know”

Take the time on the way to every single patient transport to talk with your partners and pilots. What will you bring with you? Who will get what?

Having the privilege to be a flight crew member should not be taken for granted. The flight suit is not a costume. It is not a given. It is not forever. Do not hide behind the flight suit. Earn your flight suit and continue to earn your flight suit throughout your career. Do not become complacent. Continually prepare. You don’t have to be the smartest, but you do have to be the most prepared.

Jessica Picanzo Valdez is a Nurse/Paramedic with expertise in flight and disaster medicine. Jessica began her career in flight medicine with Med-Trans Corporation in June 2011. In 2016, Med-Trans expanded their education department, and Jessica is now a Professional Development Manager where she focuses on new employee orientation and clinical coach development.